Causes and Management of Urogenital

Saaqib S.,1 Rana T.,2 Asghar F.,3 Zia A.,4 Iqbal S.5 Address for Correspondence: Professor, Department of Obstetrics and Gynaecology Unit III, Lady Willingdon Hospital, KEMU / Mayo Hospital, Lahore.

Objective: To audit the causes and management outcome of urogenital fistula (UGF) at LadyWillingdon hospital. Study Design: A prospective descriptive study. Place and Duration of Study: The department of obstetrics and gynecology Lady Willingdon Hospital Lahore from July 2009 to July 2010. Patients and Methods: All patients of urogenital fistulae except due to malignancy and radiation were included in the study. History of demographic features, cause of fistula and previous attempts at was taken. Investigations included culture, intravenous pyelogram and examination under anesthesia. The method of treatment and outcome was noted. Results: 61 patients were included in the study. The formation of Urogenital fistulae was found to be more common in women of child bearing age (96.72%). Most of the patients belonged to lower socioeconomic group (100%) and to the rural areas (95%). The causative factor was obstetrical trauma in 43 (70%) cases, due to either obstructed labor (37.7%) or cesa- rean section (32.78%). Other causes were gynecological like abdominal (27.87%) and septic indu- ced abortion (1.63%). Surgical repair was performed in 58 patients. Overall success rate of different procedures was 77.04%. Vasicovaginal fistula (VVF) was found to be most common type of fistula. 43 / 61 patients (70.49%) had VVF. Repair of VVF was successful in 81.39% cases. Six patients out of 43 VVFs, had fistula of short duration and had a trial of conserva- tive management. Success rate was 50% in patients managed conservatively. Uretrovaginal fistula was found in 5 cases (8.2%) with 100% successful repair. was found in 3 (4.92%) cases with no success through combined abdominovaginal route. All the three cases of Vasicouterine fistula (4.92%) were repaired abdominally with success rate of 66.67%. There were 7 cases of vasicocervical fistula (12.47%). Vaginal repair was performed with 71.43% success rate. Conclusion: Vasicovaginal fistula was the commonest type of urogenital fistula. Transvaginal route was most successful route of repair for VVF.The commonest cause was obstetrical trauma which was preventable by improvement of health edu- cation and maternity care in rural areas. Key Words: Fistula. Urogenital fistula. Vasicovaginal fistula. Urethrovaginal fistula, Obstetrical trauma.

Introduction abdominal or transvaginal route or combined approach. The Urogenital fistula is an abnormal communication extending success rate has been associated with etiology of fistula, size 4 between the urinary and the genital tract that allows the con- of fistula and number of previous failed attempts at repair . tinuous involuntary discharge of urine through the vagina.1 This study is an audit of cases of fistula in last one year This devastating complication has profound effects on the from July 2009-2010. The objective was to find the causes, physical and psychological health as well as on the social types and management outcome of cases of urogenital life of the patients.2 .

In developing countries, fistulas are caused by either due to mismanagement of second stage and obstructed labor Study Design or after abdominal (TAH) due to lack of pro- This study was carried out at department of gynae and obstetrics, Lady Willingdon Hospital Lahore, from July per surgical expertise. An accurate diagnosis is paramount before consideration of repair.3 Numerous techniques have 2009 to July 2010. Data was collected prospectively. Sixty been used for treatment of VVF. In patients coming within one patients of UVF resulting from causes other than mali- gnancies and radiations were included in the study. Detai- 24 hours of injury and without any evidence of , immediate surgery is performed. If there is evidence of led history was taken to record age, nature of trauma, time , or tissue edema, it is better to do conservative interval of appearance of fistula and previous attempts of repair if any. Ureteric involvement was diagnosed by evi- management for 6 weeks. Conservative management invol- ves catheterization and proper antibiotic cover with good dence of hydronephrosis on ultrasound scan and intravenous nutritional supplements. Tissue reaction should have subsi- pyelogram showing flaring of dye around . Further evaluation for number, location and type of fistula was done ded before undertaking surgery. by examination under anesthesia and dye test. Methods of Surgery involves repair of fistula through either trans- repair included the vaginal repair, the abdominal repair, and

ANNALS VOL 16. NO. 4 OCT. – DEC. 2010 303 SAAQIB S., RANA T., ASGHAR F. et al the abdominovaginal repair. Postoperatively patients were Table 2: Other demographic features. given antibiotic cover with third generation cephalosporin or Demographic quinolones. Continuous bladder drainage was ensured thro- Groups Patient # % age ugh Foleys catheter. Anticholinergic drugs were given to Features relieve bladder spasms. Success was described as absence of Primipara 11 18 leakage of urine through vagina on follow up. Statistics Parity were given in percentage to describe the results. Multipara 50 82 Urban 3 5 Residence Results Rural 58 95 During one year period, 61 patients were included in the study. Socioeconomic High 0 0 status Low 61 100 Table 1: Age distribution of women with urogenital fistula. Educational Illiterate 51 83.6 Age in Years Number of Patients Percentage status Matriculate 10 16.4 < 20 4 6.55 Nutritional Malnourished 47 77 20 – 30 29 47.54 status Well nourished 14 23 30 – 40 18 29.50 Table 3: Types of fistula. 40 – 50 8 13.11 50 – 60 2 3.28 Type of Fistula Number of Patients % ages Uretrovaginal 5 8.20 Majority of patients belonged to reproductive age group Vasicovaginal 43 70.49 59 (96.72%) while a small percentage belonged to the age group above 50 years. Maximum cases were in the range of Urethrovaginal 3 4.92 20 – 30 years. Vasicocervical 7 12.47 Demographically, 50 patients (81.96%) were multipara, 58 patients (95%) came from rural areas and 100% were vasicouterine 3 4.92 from the lower socio-economic strata. Majority of patients (83.6%) were illiterate and malnourished (77%). patients with VVF less than 48 hours were managed conser- Obstetrical trauma was found to be the commonest cau- vatively. They were catheterized, antibiotic cover was given se of fistula in this study. Obstructed labour was responsible according to urine culture report and multivitamins and high for 23 cases (37.70%) and 20 cases (32.78%) were post LS- protein diet was advised. Patients were sent home and were CS. Other causes were TAH (27.87%) and one case after called after 6 weeks. In three out of these 6 patients (50%), septic induced abortion (1.63%). conservative management failed and surgery was performed VVF was the most common type of fistula encountered. after 3 months. In rest of the 58 cases surgical repair was Less frequently, urogenital fistulas were found to occur bet- performed through either abdominal route or vaginal route ween the bladder and or ; between the ureters or a combination of both routes. Postoperatively, all the and vagina and between the and vagina. patients were kept catheterized for 21 days. Continuous Seven patients presented within 48 hours of onset of urinary stream was maintained. Constipation was avoided urine leaking, one case was successfully repaired while 6 by laxatives, protein rich diet and multivitamins were prescribed. Urine culture was sent every 4rth day for microscopy and culture sensitivity. Septic Antibiotics were given according abortion, 1, to the report. Obstructed Post TAH, 17, 2% 77.04% of all patients were labour, 23, Obstructed labour 28% cured while rest of the patients had Post LSCS 37% a recurrence. Recurrence occurred Post TAH in those cases where fistula was Post LSCS, Septic abortion complex or large or involving ure- thra and in those who already had 20, 33% failed repair. Vaginal route was most com- Fig. 1: Causes of Fistula monly used route with highest

304 ANNALS VOL 16. NO. 4 OCT. – DEC. 2010 CAUSES AND MANAGEMENT OF UROGENITAL FISTULA

Table 4: Management outcome. location, surface area, number and no of previous repairs. Different studies show varying success rates for abdominal Number of Cured Success Type of Fistula and vaginal routes. Patients Cases Rate % In this study, Uretrovaginal fistula met 100% success Vasicovaginal 43 35 81.39 rate where as in VVF success rate was 81.39. This success rate goes well with other national and international stu- Uretrovaginal 5 5 100% dies.7-9 Urethrovaginal 3 0 Nil Patients with simple, small, low lying fistula were sub- jected to vaginal repair which has contributed to a better Vasicouterine 3 2 66.67 success rate as compared to the abdominal route where Vasicocervical 7 5 71.43 cases with repeated repairs, high up, large and complex fis- tula were selected. All the 3 cases of Urethrovaginal fistulas Total 61 47 77.04 had failed repair for several times, their fistulae were large in size with extensive tissue loss and fibrosis. Their repairs Table 5: Method of Repair. were attempted by combined abdominal and vaginal routes but they failed to heal due to tension in approximation of # 0f Cured Success tissues and failure to separate the layers properly due to Management Cases Cases Rate scarring. According to the WHO 1991 Report on Obstetric Fistu- conservative 6 3 50% lae, women with fistulae come almost exclusively from poor Abdominal repair 15 9 60% families and communities.10 This goes well with results of this study. The majority of the total births in this study were Vaginal 40 34 85% conducted by Dai’s or untrained birth attendants. This is due Combined route 3 0 0% to poverty, illiteracy and to some extent ignorance of people to utilize health facilities. These obstetric fistulae can be prevented by educating the population to utilize maternity success rate (85%). Success rate of abdominal repair was services. Labour should be supervised by trained health per- 60%. sonnel and difficult labour referred early to appropriate hea- Combined repair was used in 3 cases of VVF involving lth care facility. the urethra. Unfortunately none of them was successful ope- A smaller but significant number of cases were iatroge- ration due to repeated repairs (3 – 5 times). In one of the nic due to cesarean section and instrumental deliveries per- patients bypass surgery was performed while rest of the formed by doctors in rural areas. This highlights the need patients were lost to follow up. that doctors providing maternity services in these areas sho-

uld attend refresher courses at regular intervals in teaching Discussion hospitalsto learn the best operative techniques and newly Obstructed labour is the major cause of urogenital fistulas in 5 appointed doctors should have proper training for instru- the third world countries like Pakistan . Birth trauma occurs mental deliveries and caesarean section. due to prolonged and difficult deliveries that can cause Surgical fistulas can also be prevented by improvement ischemic necrosis of the vaginal vault and the posterior bla- in surgical expertise in rural areas. dder wall, causing them to slough off, resulting in passage of urine through vagina. The commonest cause of fistula in this study is obstructed labor and cesarean section. Conclusion Urogenital fistulae are of varied types, with VVF being VVF is found to be the commonest type of Fistula. It is the most common in this and other national and interna- mostly due to obstetrical causes. Obstetrical trauma was the tional studies.2,3,5,6 On the suspicion of a VVF, a thorough commonest cause of VVF and transvaginal repair was the vaginal examination should be done, in order to identify the most successful method of repair in this series. Despite the exact size and location. Special care should be taken to find good results of surgical repair, attempt should be focused on out ureteric and uretheral involvement as urologist help is the prevention of VVF. With proper health education, required for these procedures. improvement in the quality of surgical practice and mater- There are varied approaches for repair of these urogeni- nity services in the country, the incidence of genitourinary tal fistulae viz. abdominal and vaginal. The abdominal appr- fistulae will be reduced. oach may be used to treat all types of UVF and preferred when there is ureteric involvement. The vaginal approach References involves a tension free fistula closure with or without tract 1. Riley VJ, Spurlock J. Vasicovaginal Fistula. 2006; excision. [cited 2007 Jul]: [25 screens]. Available from URL: The success rate of fistula operation depends greatly on http://www.emedicine.com/med/topic 3321

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